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This is VAERS ID 1110757

History of Changes from the VAERS Wayback Machine

First Appeared on 7/2/2021

VAERS ID: 1110757
VAERS Form:2
Age:
Sex:Female
Location:Foreign
Vaccinated:2021-01-16
Onset:2021-01-17
Submitted:0000-00-00
Entered:2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Other      Purchased by: ??
Symptoms: Death, Loss of consciousness, SARS-CoV-2 test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-22
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Dementia
Allergies:
Diagnostic Lab Data: Test Date: 20201226; Test Name: COVID-19 PCR test; Test Result: Positive ; Test Date: 2021; Test Name: COVID-19 PCR test; Test Result: Negative ; Test Date: 20201224; Test Name: COVID-19 rapid POC test; Test Result: Positive
CDC 'Split Type': DEPFIZER INC2021120226

Write-up: Exitus letalis; Unconsciousness; This is a spontaneous report from a non-contactable physician downloaded from the Regulatory Authority-WEB, regulatory authority number DE-PEI-PEI2021002012. A 79-year-old female patient received BNT162B2 (COMIRNATY), via unspecified route on 16Jan2021 at single dose for COVID-19 immunization. Concomitant medications were not reported. The patient''s medical history included dementia, unknown if ongoing. On 17Jan2021 the patient experienced unconsciousness and died on 22Jan2021. The cause of death was unknown, and it was unknown if an autopsy was performed. Lab data included COVID-19 rapid POC test on 24Dec2021 with positive result and COVID-19 PCR test on 26Dec2021 with positive result and on unknown date in 2021 with negative result. Relatedness of drug to events by Regulatory authority: A. Consistent causal association to. No follow-up attempts possible. No further information expected. Lot/batch number was not provided and unable to obtain.; Reported Cause(s) of Death: Unknown cause of death

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